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Does my Insurance Cover That?

In-Network Vs Out-of-Network Therapy Services

If you are reading this, then you are probably interested in seeing a provider out-of-network (OON). Or are at least intrigued as to what the benefit is from seeing a provider that is out of network with your insurance plan.

To demonstrate the benefit of seeing a provider that is OON, first we must understand the value of your current insurance plan. When you and your health insurance share fees and payments for your medical care, it is called cost-sharing. Examples of cost-sharing are your deductibles, coinsurance, copays, and out of pocket maximums for each health care visit. Understanding how insurance works helps you make a better decision to suit your healthcare needs.

Deductible

A deductible is the amount you pay for health care services before your health insurance begins to assist with payments.

Lets say your plan’s deductible is $2,700. That means, for medical service rendered, you’ll pay 100% of the the medical bill until the amount you have paid reaches $2,700. After that, you will begin to share the cost with your health insurance by paying coinsurance and copays.

Coinsurance

Coinsurance is your share of the cost for your medical expenses. This rate is normally predetermined as a percentage of the fee schedule that is billed based on the services rendered. You start to pay coinsurance only after you have met your plan’s deductible.

Say Johnny has plan is a 70/30 for outpatient therapy services. That means his insurance plan will cover 70% of the bill and Johnny is responsible for 30% of his physical therapy expenses, or known as his coinsurance. Remember coinsurance only comes into effect once your deductible is met. If the services rendered for physical therapy are higher than what his plan is willing to pay, then Johnny is responsible for the remaining balance.

Since Johnny has a PPO, he has the option to see a different provider that is OON if he chooses. Johnny chooses to see a provider out of network, his plan will still cover the cost of physical therapy services.

CoPay

A CoPay is a fixed amount the patient will pay for health care cost, usually due when the service is provided. The amount can vary based on the service being provided.

For example most in-network insurance copays are $50 for physical therapy.

Out of Pocket Maximum

Your out of pocket maximum is the maximum amount of money you will be required to pay for your health care in a Calendar Year. Once you have met your plans out of pocket maximum, your health care insurance will cover 100 percent of the bill until your health insurance resets on January 1st of the following year.

In order to appreciate the true value of your health insurance you must look at it from the in network vs out of network scenario.

In Network Insurance Scenario:

Johnny saw his local in-network physical therapist and was prescribed a plan of care of 3-4x per week for 12 weeks. A total of 36 to 48 visits! Lets assume each visit will last for 45 minutes plus TENS application for a total of 60 minute sessions. Johnny’s deductible is $2,700 and has only paid $1,000, with $1,700 remaining.

Each visit will cost Johnny $155 each session until he has reached his plans deductible. That means for the first 11 sessions Johnny is responsible for his entire bill and will pay $1,700 out of his pocket with no chance of reimbursement. For the remaining 25 to 37 visits Johnny’s insurance will pay 70% of his expense and he is responsible for 30%. Because his insurance does not know how much they will be charged, Johnny pays a $50 copay for each remaining session. If Johnny follows his plan of care, he will pay $50 x 25 visits to equal $1,250 in copays.

Johnny paid $1,700 + $1,250 for therapy to total $2,950. But wait, your insurance provider has decided they are not paying for the full service provided. TENS, HEAT PACKS, COLD PACKS, BIOFREEZE, ULTRASOUND, and MASSAGE are not covered services. When you agree to a plan of care, the in-network entity will have you sign a waiver for balance-billing. This means anything your insurance decides they do not wish to pay, you are directly responsible for. If your physical therapist provided these services you will be billed accordingly for each service provided directly. You will receive this bill in the mail roughly 4-5 months after therapy has ended and your insurance has examined your plan of care to determine what they wish to not pay for.

Out-of-Network Insurance Scenario:

Lets say Johnny has decided to see his physical therapist out of network with Rosi Physiotherapy. Because our Doctors are receiving payment upfront, they do not need to provide an excessive plan of care for your injury and have elected to see you 3x/week for 4 weeks. A total of 12 visits at 60 minutes each. At Rosi Physiotherapy each session is the same price regardless of what service is being rendered. This is known as fee-for-service. If we look at the same scenario with Johnny, he needs to pay an additional $1,700 until he reaches his deductible of $2,700.

Each visit for Rosi Physiotherapy is $200. The total plan of care for Johnny is 12 visits x $200 each visit = $2,400. Rosi Physiotherapy also provides a discount for one month of service to not exceed $2,000. Johnny will pay Rosi Physiotherapy $2,000 for his plan of care. Once Johnny has completed his plan of care, our doctors will furnish a “superbill” or medical itemized receipt for him to submit a self claim to his insurance. His payment of $2,000 is applied to his deductible and Johnny is now eligible for up to $300 in reimbursements as this what what charged beyond his yearly deductible.

Now lets recap, as both of these scenarios will vary widely depending on your current health insurance plan.

In-Network Scenario:

Pros

Out of pocket expenses are split up throughout Johnny’s plan of care

Cons

Prescribed an additional 24 to 36 visits for the same injury

Took 3 months longer to complete his plan of care

Total out of pocket expenses were higher compared to out-of-network provider

Out-of-Network Scenario:

Pros

Timely recovery (1/3 the time as with in-network providers)

Only saw a doctor of physical therapy for his care throughout the entire plan of care

No copays for each visit

Eligible for reimbursement from his health insurance if he has met his deductible

Cons

One upfront payment for his entire plan of care

So back to the original question. Is seeing a provider out of network right for you? If you prefer to have high quality care every time, want optimal results in a much shorter period of time and value your mobility. Then the answer is absolutely yes, Rosi Physiotherapy is the right provider for you.